title: Drugs associated with teratogenic mechanisms. Part II: a literature review of the evidence on human risks.
abstract: OBJECTIVE
  What is the current state of knowledge on the human risks of drugs suspected to be associated with teratogenic mechanisms?
  
  
  CONCLUSIONS
  Evidence for the presence or absence of human risks of birth defects is scarce or non-existent for the majority of drugs associated with teratogenic mechanisms.
  
  
  BACKGROUND
  Medical drugs suspected to be associated with teratogenic mechanisms are dispensed to a significant proportion of women in the first trimester of pregnancy. However, an overview of the current state of knowledge on the human teratogenic effects of these drugs is lacking.
  
  
  METHODS
  We performed an extensive literature review of studies in the English language which examined the associations between selected drugs and specific birth defects. The literature was identified from MEDLINE and EMBASE from database inception (January 1946 and January 1974, respectively) through December 2012 using 287 terms for the drugs of interest. We only included studies if they specified birth defect subtypes and, specifically for cohort studies, involved live born infants.
  
  
  METHODS
  Of 14 406 potentially relevant articles, 556 full-text articles were assessed for eligibility and 250 met the inclusion criteria. The studies included were divided into four categories according to their design to increase the validity of our study.
  
  
  RESULTS
  Epidemiologic studies assessing teratogenic risks were identified for less than half of the drugs included in the review. A substantial variation in study design and data collection methods was observed. When the data collection method is of questionable validity, study quality may be affected considerably. For only 15 drugs of interest, birth defects were assessed in at least 1000 infants in cohort studies, and 13 of these were associated with one or more specific birth defects. The majority of associations observed in case-control studies are as yet unconfirmed. For most drugs and drug groups, however, the numbers of exposed infants studied were too small to draw any conclusions regarding their human teratogenic risks.
  
  
  CONCLUSIONS
  The validity of our review is limited by the validity and reporting of the studies from which the data were extracted. Some relevant studies might have been missed owing to the exclusion of articles not in the English language and publication bias.
  
  
  CONCLUSIONS
  It is a cause of concern that the drugs most often dispensed in the first trimester of pregnancy are not necessarily the drugs for which teratogenic risks have been studied. Future studies should focus on those drugs that are most commonly used during pregnancy and for which the teratogenic risks are unknown, such as iron preparations, serotonin receptor agonists or antagonists, drugs used in fertility treatment, dihydrofolate reductase inhibitors.
  
  
  BACKGROUND
  Marleen van Gelder was supported by the Netherlands Organisation for Scientific Research/NWO (grant no. 021.001.008). No competing interests are declared.
  
  
  BACKGROUND
  N/A.
authors.affiliation: Department for Health Evidence, Radboud University Nijmegen Medical Centre, Nijmegen 6500 HB, The Netherlands.
authors.forename: Marleen M H J
authors.initials: MM
authors.lastname: van Gelder
authors.forename: Lolkje T W
authors.initials: LT
authors.lastname: de Jong-van den Berg
authors.forename: Nel
authors.initials: N
authors.lastname: Roeleveld
mesh_terms: D000014:Abnormalities, Drug-Induced / Q000517:prevention & control*; D000818:Animals; D016022:Case-Control Studies; D015331:Cohort Studies; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D012306:Risk; D013723:Teratogens
chemical_list: D013723:Teratogens
keywords: congenital abnormalities; pharmaceutical agents; pregnancy; teratology